 Good morning everybody, so we're gonna get started right on time today We have a couple presentations first is by one of our founding fathers dr. Crandall on Of the Moran of the Moran I Didn't say grandfather Um, and he's gonna talk about minimally invasive glaucoma procedures and then Adam guess There's one of our new cornea fellows coming to us from CPMC is gonna talk about the patient that I hope everybody had a Chance to at least take a brief look at upstairs Young lady with Ellers-Danlos. Thanks. All right. I just want to kind of update people on what's going on in the glaucoma sphere because really lots of things are changing and with a recent FDA approval of ice and I thought I'd just bring up a couple bring up the Talk a little bit about the ice tent and then a little bit about some of the new Procedures that were involved in we'll be starting phased two trials in in two new Glaucoma devices pretty soon So, you know what if you look at glaucoma surgery in the past, you know It's basically if you if you actually look at a trabeculectomy done in 1973 say Let's say 76 because it in 73 most of them are still shape procedures And then look at the procedure now. There there aren't there really isn't a lot of difference I mean basically it's the same technique originally Karen's described the Trab is a five by five flap And a much larger adectomy than we do so the main modulations that we've been doing Over the past 30 years have been at the healing end mitomycin sponges smaller tubes or smaller PIs no PIs all sorts of stuff, but basically the trabeculectomy has been The Ancel is the the gold standard With the problem the problem with it is of course is the long-term Complication rates if you look at studies We do quite well for two to four years and most average trebs last about eight and a half to 12 years which is Okay, if you're if you're dealing with 75 80 year olds But certainly many of our patients in the younger group and all you you all see these up there dysthetic blebs leaking blebs you know uncomfortable hypotenuse maculopathy and The worst of course would be endopthamitis And so the the problem is we'd like to really work at where the pathology is which is in the juxtacanalicular tissue And see if we can work in that and we've been working on this for about 20 years And it's been about five steps backwards and maybe six steps forward. I don't know what are those two And the question is what do you think will happen in 10 years? And we probably will still be doing traps a variation of it there We have now two supercortal drainage implants one that's The gold shunt and I'll show you that and then the one there's the new one that we'll be doing Which is a which is a variation of that. It's called the eye pass And that's that's in phase three trials in Europe and we will be part of the phase two trial here And there'll probably be newer glaucoma procedures that will do it. So if we look at the In the past, you know go because of the long-term complications surgery was basically a last result excuse me last resort and But if you look at all the big trials that have been done It's been basically shown that the long term Doesn't matter how you get the pressure down As long as you get it below 17 and almost all the time You got about a 90 percent chance in most cases of not losing any further vision From the from glaucoma and if you get it down to 12 it jumps up to about 92 93 percent chance Moving the the low tension glaucoma is out of the picture just statistically on on the average ones But so, you know, what is why most everybody that leaves does in general ophthalmology Actually, they were the surgery is really dropped off as we've been as we've had more potent Any glaucoma meds such as the prostaglandins and the com again co soft all those new drops and So most people end up out of practice about five to ten Trabs by the time they're done, which is technically I think enough to do it But a lot of people for many years did not do it So so a lot of the glaucoma people like Norman and Jason and I everybody would refer Cases into so that their skills actually were getting fairly minimal Although the cataract skills were we're still quite good and the new devices are really I think aiming at the cataract surgeon We'll talk a little bit. That's a political issue, too as well there can go out coma society tends to back back off on some of these these issues, but The problem with traps and everything that we've done in the past is it truly is not physiologic If you think about it, you're basically making a hole You know if you go back you could go back to Elliot's stuff where they basically did a tree fine in the sclera Or the Pugelblad where you make a hole transclerally I mean these that's basically what you're trying to do in the whole time Really what you're trying to do is is depend depend on that, but you fight it It's kind of a weird combination if you don't get it you get hypotony if you get too much of it Then it seals down so what you the art of glaucoma surgery is really not in the technical aspect of doing the surgery It counts, but that isn't the biggest deal. The biggest deal is the post-op management and by the few Sutralizes we use mitomycin in the clinic now Subtenons so there's lots of things that we do to modulate the healing process But if you look at it, I mean look at the Complication rate. This was a retrospective study. It's Gary Congden and Pittsburgh did and He's a great surgeon. These are his cases, but that's a pretty pretty ugly complication file profile, so you know those are those are not Things to be forgotten about quite quite surgically So what we want to do if we can come up with something that we can avoid a bleb and increase Outflow it would be nice and that's basically where we're where most of the research is going into right now And I'll show you a couple things as we go further down. There's other also. We do use ECP here And it is very helpful in some cases. It's it's less predictable cause a lot of inflammation post-op at least initially and Since it probably truly doesn't Destroy the the ciliary body as it as an external diode does it tends to be somewhat Oh three to five year range maybe six years But again, these are usually in the eyes that have retinal issues or have other issues I think about the last ten that we've done here have all been Combined with with the retina service and then of course, they'll be always modified Trabs tube shunts the tube versus tap trap study, which was not a good study as everybody knows they took To get into it. You had to have already failed a trap So it wasn't their best shot at Trabs best shot It was people that already failed and the outcome was fairly similar although the five-year data somewhat supports the Tube group in that setting but And there are certainly people that go right to tubes you live in Miami You're probably gonna get a tube if you have pressure of 30 We're less we're more reluctant to do that because of the six success we can do with the Most of the of our population here, which is Caucasian not African-American or Cuban which has a slightly different profile. So Let's look at some some ways of doing that if we look at sub cons flow, that's that which would be similar what we have the The non-penetrating would fit into that category Google blades Transcillary filtration the mini shunt and the MIT I which is out of Miami We'll talk quickly show that you look at trabecular flow. And this is where people are really getting Interested right now The I pass which is which is the study that we will be doing here This cookie lots of which we've been doing here for 15 years 20 years direct home and then the ELT ELT is tied up in in litigation right now. It's a patent fight between Michael Berlin and LA and The German company and so we the US we have not we don't have it available And probably five years before it is available But it is it is a way of doing that and then to regular hint enhancements slums canal scale spacing procedures, which are really done for originally for Presbyopia, but also noted some somewhat Lower flow. I mean increase outflow and then the gold chunk which is Nick here. I don't think he's here Oh, there he is Nick You have two of those gold chunks. Is that and you want to just describe what you saw which was I think a surprise to everybody There's not there's not very many in as the problem. It's a pretty high rate right And the interesting thing too was because it was gold it did not require They didn't require the phase one studies so they allowed them go right to phase two studies Which was interesting so they didn't have a safety profile on the gold shunt even though it and so the I pass is actually material that's similar to to cardiac stents and It is much more biocompatible. They have a lot of rabbit studies and they have a lot of initial Reasonably good results. It's very quick very easily easy to do It's a really interesting study, but we'll be starting that pretty soon So just quickly everybody knows about the I stent. I mean the mini shunt excuse me and it's a small tube It was originally designed for a third world ophthalmology Which which was it was supposed to be a two-minute procedure that you could do and it was basically under conjugal not was not under a scleral flap and Basically would put a nail inside the iron that would drain. I did work Short-term, but because of its location. There are lots of erosions And there was not the success rate in the third world is actually quite low and so it was abandoned for that but Optinol at the time which was then ultimately bought out by Alcon talked to a number of surgeons and Marlene Moster and Leon Herndon most are at Will's Herndon at Duke did a couple of studies looking at it under flaps and it turns out that there are some advantages to it It's pretty easy to place and so we That's something I've been doing a lot of the advantage from from a surgical standpoint is you don't really you don't have to make The ectomy portion of it you put you're putting this under a flap and What it does then is it has a consistent outflow Some people feel it's too much so they get they're trying to modulate the Lumen size, but if you seal it down pretty well, and then you can suit your lysis later It actually works pretty well, and you don't have to do your edectomies But for the most part we've not been doing their edectomies certainly on pseudo-fakey guys or in eyes that we're doing combines or in Hi, my hopes for at least ten years and have had no complications, but actually most Guacoma guys do Excuse me do do an erudectomy routinely and there's inflammation and Ipema's and stuff so like we then we'll also look at summer. We still do a variation of the viscocaneloscopy, which was Robert Stegman not it out of South Africa and deep scurrectomy with a collagen implant Now the deep scurrectomy with collagen implant is still the the number one procedure now done both in France and In Switzerland and parts of Germany, so it it has lost its momentum in the United States But it's still a very highly used procedure the rest of the world So and we we have a lot of those pace it basically this is similar what we did last night to the guys that were there last night We had to remove a tumor a malignant melanoma just a very small one that Was found was about a two millimeters by two millimeters So what what what I did was basically this you do a square plop like you're doing a trap And you dissect a second flap, which is this one. So the trap flat is this The inner wall is this and last night I went all the way down to to Coroidal great right here, and then we peel that off and popped out the tumor This is the inner wall of Slim's canal and you can actually peel that off you peel that off you still have about 20 microns of Tissue under it But it does permeate through that and that's the theory that you're reducing that resistance to outflow at that level It's not it's not as difficult as it looks to peel that you can see here beautifully this this is Again, Slim's canal. This is decimates membrane. This would be scleral spool right here So it's it's technically Difficult to do and that's why one of the reasons why it hasn't Taken off. It's but if you do it well, it works quite well And we use we did a collagen implant this came out of Russia Originally when they was designed there've been lots of different ones there's now one called oligin which is a material that fits right into the scleral flap and creates a lake a lake effect and This one the collagen lasts about six months, and then it's gone and produces a scleral lake and but Theoretically you get outflow through there same as you would through a trap. This is one where the where the I've done a laser What you can do is laser go near photo. I'll show you a nice picture here Then I'll show you in just a second. So you really get you get through the collector channels So it's similar to viscocanolostomy subcons so it's similar to Trabacillectomy and supercordal so it's similar to the other mechanisms So and they do work quite well, but again, they're technically difficult The theory was of course to reduce cataracts, which it did Information and hypoteny which it certainly did but most people found it just the learning curve is pretty steep This is one of ours about five years post op This is an inner wall. You look at you can see the decimates Window here, and you can actually laser that it's so thin. Just use a yag laser with with a Little bit of power right in that area, and then you can you can pop right through this is pre This is post Yag so you so you can do it as a stage procedure if you will When that when the pressure starts to right raise and then share away and my moods who have the world's biggest groups that about 50% of theirs end up being converted into this but you know the complication rate is very low so they get out they get a high high rate in it. That's the Swiss and Egyptian groups and then Jason and I can I did a meta-analysis of the dad and it shows it really does work so Now we're trying to look at ways to really work at this Level here Shulam's canal outflow and that's what most of the devices are are look at so we look quickly I won't we have a ton of stuff But I want to show you a little bit about the I stand and the Quebec tome and possibly variations of ELT which we hope will be available This is a patient of mine. We did a this is the I pass now the I pass never it did It did make FDA that had a Approval but it wasn't it wasn't significant enough So basically what we were doing was was was like a cardiac stent We put to these this is a silicone and the new materials are not silicone The I pass and the others are really cardiac much more biocompatible and don't don't clog like this actually didn't we just make a Sort of a squirtle flap same kind of level Open Shulam's canal and stick the two stick these two tubes into Shulam's canal like a like a stent and then this went into into the anterior chamber. So you would make a small little Three or four hundred micron incision to put it in this is one of the patients right at the time of surgery and you can easily see the Blood so whenever the pressure drops blood gets into Shulam's canots a good way to To identify the anatomy if you're doing goniatomies or you're doing I stand so you can use it when the pressure is low Slim spills with blood and that was the show that it was in fact working quite well. This is a View internally you can see this This is what we're looking for watch what happens when the pressure. This is from Romer's segment. There it is That's blood and slums canal The interesting thing is you can even identify both heart rates and You can identify outflow in this video. I think this is segment is the only one in the world that has this video it's a hundred thousand dollar camera and It was only designed for him and they only made one So nobody else can get it. It's amazing to see what's going on in slums canal You can really see the anatomy quite quite beautifully. I think I don't know if anybody's seen it Here's this there's a collector channel. Now. Why is that important? It turns out that if you put an eye stent near the outflow One or two of them work well if you happen to put it away it doesn't work well and That's the reason for the the eye stent on steroids, which will be known as hydrous. That's our study And I'll show you that in just a second. So We look at outflow. That's what we're looking at is that these little aqueous things that we're filling with with the fluid These are die cast Look at outflow. This is out of the Oregon group. These are macaw monkeys. I believe but it's pretty fairly similar So again, we're looking at trying to figure out how to get past this juxtacanolicular tissue Which is right here And that seems to be the outflow everybody still believes that's where the problem is So let's look at ways to do that one of the ways was was this cocaine elostomy, which is what Stegman did now His population is different from anybody's in the world. It turns out genetically That if you have pure African blood No Caucasian nothing else. It's a very aggressive type of glaucoma. So in South Africa He would have patients that would come in mid 30s point nine nine cops pressures of 50 we just don't see that very often and We were actually going out with Hageman Hageman's group to because there's two or three generations We can that segment is going to get for us and we hope to isolate that gene Because it would be really important because it's just nobody else. There's no other place that I know of where you see that kind Of a population that is so young. It's so aggressive And so this cocaine elostomy actually works in that group because they started pressures of 4045 and their outflows are different And so that's why his data was not transferable to the United States and we're you have a fairly bad name academically because they did a lot of people just didn't believe this data because they couldn't reproduce it I don't I think the problem is they just don't have that population. It's just unbelievable You look at it every one of his patients in that paper he did for AJO and it was pretty pretty interesting But at any rate one of the things that's come out of that is canaloplasti, which which we do here and We have a nice the canaloplasti is in micro catheter goes all the way around I'll just quickly show you a little video get to it You can inject this cocaine elostomy the hope eventually is maybe we can figure out a drug David might be able to do this to figure out a drug that you can put in to this slums canal to either increase outflow or or you know rotor root the the canal so it works better You basically pass it around. I'll just get to the video. There's a lot of evidence Laboratory evidence that it acts like pyrocarpene because you we're gonna put a stent in the procedure This was work before he passed away of Johnson Showing that whenever you put the tension on a slums canal outflow increase when he lowered the tension decrease This was at the Mayo Clinic And so what we do was just show you one of those this is an internal View of some of the patients with the stent. You can again do laser gonioplasti So this is just to show you I've already made the inner wall So you're basically doing a viscocaine elostomy, but instead we're gonna do it for 360 degrees the little red Heat is a allows you to track it as you move around so what I'm gonna do is I'll turn off the beat I'll turn off the the microscope light here in just a second Basically what we're gonna do there's there is in slums canal and you can watch it go all the way around and then what I'll do is I'll tie a Tenno pulling suture to it and put it leave it in slums canal and then you put the tension on the problem is You have to raise the pressure high enough so you don't put you don't tighten it too much So you and some of the pediatric guys are actually using this now to do the internal goniom is a really beautiful way to do that And so it's gone all the way around the eye and it's inch So it's inch lens canal all the way around and then we'll just tie the suture to it and then pull the suture all the way around and then here Sometimes it The issue of course is what whether the correct tension so what we do is we have a Ultrasound that we can use at the time to make sure that we're inch lens canal to make sure that we get some some distinction of it so that as you can guess this is not a 22nd procedure this is different this is the ultrasound Beautiful way we can identify a lot some guys are very low Acting products. So but it's a good way. I want to show you One of the again, this is from Bob's Steak Robert Steakman. It's one of the most amazing videos you're ever gonna see I think other than that other one that I bought from him. Okay. There it is inch lens canal Going around you just see the device. It's unbelievable. You haven't ever So this is the external and then use the the other stuff is the internal stuff as it goes around So here's pulling out same same way This is the tightening trying to figure out exactly and they're working on ways of trying to to figure that out, but it's Again, it's technically a difficult procedure and there it is inside the eye So this is the end of the procedure. There's the decimates window and you can laser that so if it's too tight You can pop it with the egg and then you can open up slums canal These are ways of working it at this level. So the canal plastic is an interesting device Let's look at ELT. This is the one that it is actually Done really well in Germany. One of our ex fellows Is doing a lot of these and it seems to work right. Well, it's the internal opening you've blasted through but it's again It's it's an opening the trabecatome. We have here. I haven't been too thrilled with the outcomes But basically what you're doing is you're doing a goniadne with the with a cutting device. I'll show you a little Here's a video of this You just go in Bore everybody with the glaucoma. We get pretty excited about this stuff and most of these are done at the end of the cataract surgery that the reason why I'm bringing this up is because one of the one of the issues that we're going to have is possibly who who If you use it on somebody who had saved mild or ocular hypertension and get a good result It's gonna be hard to look at data once it hits the That has a so it's a cutting you put that into Schlem's canal and then there's a there's a electrocatery that basically cauterizes Nick have you seen any eyes that have had this? And I don't think I have either so this is just you just to show you the The device goes in you can you can actually if you move around you could obviously do all almost the whole thing But most of the time we do about a hundred and twenty hundred and thirty degrees and it so you activate the foot pedal And it just cuts as it goes around and generally what's happened is at least Rabbid eyes and then most eyes the problem is usually turns out you get generally scarring that comes later So it's like it's like an internal Go neotomy, so let's go This is the one that what that has last two weeks ago was received FDA approval and this is the this is the Microstand the ice that and it is so it there the the thought is to place In actually an unfortunate in the United States you get one for seven hundred and fifty dollars And they're selling it in Germany and every about every place else in the world. They put three They're trying to find trying to luck out and put it towards Hopefully near an outflow facility when you when you do when you just place it randomly in the eye And it's almost always nasally. It's all always done almost always done in combination with cataract surgery It's technically pretty easy to do We'll be doing these in about three weeks here because I've just received FDA trials I was in the one of the early trials about ten years ago that took them a long time to get it Don and basically what you do is you put it into Schlem's canal. It's got these little Anchors that prevent it from migrating And then the so you're bypassing the juxtacanolicular tissue And this is one in the eye so you can see it's easily in Schlem's canal And you know you can identify obviously the canal and look for Sclerosis spur and we'll put in the top third of the TM. So it comes in pretty easy. Here's one There's two in the eye. This is this is basically what's being done everywhere else in US but they can't of course say that the problem is is you only put one in you get two and a half millimeters compared to fake Now there is data that shows that for each point over a five-year Lifespan that that there's there is a significant decrease in in the mean deviation for on Visual fields so one point or two points does make a difference long term But does it really you know, it's pretty hard to prove but it that was from the ages data The advanced glaucoma intervention study, so it is something to think about and but what we're working on We will be doing an ice tent versus hydro study here. And let me get to the hydrous Let's get out of this because I know we're running out of time. I just want to show you a hydrous But that is so so iVantis is already FDA approved and Let's go So the hydrous is that is the ice then on steroids So what it's going to do is it's going to take it's going to cover Almost 90 degrees and it's a material that is pretty biocompatible This is so the ice dance here the hydrous is here So you I don't think there's any way you can miss outflow by putting it in 90 degrees It's technically not too difficult to do in the injects it in so these are the out these will be the outflow into device into into The outflow system, and then this will be facing me TM I think I'm a video here. So basically this is what it looks like in the eye and So we'll just see this device going in See similar so it's a very similar to the ice tent. We put it in You have a nice that one, but that's this one. I think it's a little bit more interesting to look at Identify the anatomy you rotate the patient's head nine about 45 degrees and you tell your microscope back Then you can beautifully see Swim's canal just we indent with this injection device And so this will let this adds about 10 minutes to a to a cataract procedure And the initial the phase one Trial is done the phase two is almost completed right now, and we're going to be in the second part of phase two And so the the theory is you're you're increasing physiological outflow and It's something that could be done at the end of the procedure now with you look at the data that We're just faker reduces pressure. This probably at least in the initial stuff is going four or five six points When compared so the first trial was was this versus Faco And that's one that's ongoing now in the United States It's been done everywhere else then the second one the one that will be in this ice tent versus Versus hybrids, so we'll be comparing we're gonna put we've got there We're gonna put two in so hybrids is gonna buy two of them for us So we've released compare it to to at least what's used in the rest of the world So it's an interesting time. There'd be a lot of initially It's Chris Calcuttaire by the way That's he's the it's his yeah, he's the CEO of Glaucose and so what they've done is they've they've been there They're I said one of those out Similar to what he did at AMO is about 200 people in the United States that can use it to start with and then When that data comes in then they'll they'll sell it to everybody But I think things like this will see being used at the time of cataract surgery. That's gonna be that's the AGS's point is that It's probably gonna be overused So there's already negative of press that's going out. I just wanted to bring this up now So if you hear you'll hear both sides of the story it certainly is technically easy to do all of these but it's You know, it's the hydros the ice tent comes at seven hundred and fifty dollars per Stent in Europe. They're selling them to for a thousand or something like that. So they're averaging two to three. These are so they're it's not it's a significant increase in in the cost of the procedure and the high risk will probably be around my guess is around 1500 they don't know for sure what they're gonna put it up If the data is significantly better than the I stand alone, then they'll probably go up higher than that So and that's that's a new startup company that we'll see who buys them They have good research going on. So it's good stuff. So I think there's a pretty exciting time in glaucoma But I think probably in stone certainly in five years and probably ten Does that be where you are? Come on Joe At any rate, I will still be doing traps. So and Goniotomy is not the other stuff that it's The technology is getting there and the exciting thing for me being that Faco guy who saw the incredible changes that occurred from 73 to 2012 is unbelievable every two months something's different and Finally the glaucoma group is coming into that realm. So there's lots of innovations There was no innovation other than, you know, how to cut it will be your whole Outflow modulation. So this is pretty exciting stuff. And I think So you'll be hearing from us when when the when this when the trials start we'll be looking for patients basically that are mild mild to moderate Mean deviation in the minus eight range somewhere zero to minus eight range Ocular hypertensives if you think they're at high risk would be okay for the study And then we'll look at the surgical outcomes in a few years and maybe five years from now we'll have another procedure. So thanks Any questions Nick, that's correct. That's correct. Yeah, it's a turf. It's a turf battle. Yeah Yeah Well, they yeah, that's that's exactly the point. Yeah, they it's a turf battle to them, you know in the past everybody's so We're the AGS is saying and sort of their politically correct term. That is we think it'll be overused But you know who cares if it works There's only been studied in one of the cases, you know, Weinrebs lab has has the ability to look at They haven't looked at the actual outflow, but they looked at pressure at nighttime and it and they do they do work at nighttime And this is stabilizes the pressure all seems to stabilize the pressure all day. So it's probably You know, they the outflows studies at nighttime are hard to hard to do Without lights and stuff, but they have a sleep lab there at UC David or UC San Diego, San Diego, yeah Yeah Oh Yeah, that's all you know the biggest problem with five years seven seven years see we won't know really if it's how effective it is That's not true. That's not the case Correct And I think what yeah Yeah, right, that's what I was talking about with the with the inside there, and I think the The other thing too is that it's been shown now that everything that we do to improve blood flow exercise non-smoking, you know all those all that stuff Management of hypertension Improves visual outcomes. So, you know, we're now spending a lot of time talking about Activity-based stuff for our patients as well. They'll make it three oils all that stuff does does make a difference Possibly that's correct And and and not lowering pressure at nighttime blood pressure big deal. So I Yeah Yeah, that's that's real. That's real and so and one of the What we what I do is Yeah At nighttime so we're I'm asking the most of the bad ones I'm asking them to take their their medicines not at night time and working with the family practice I know Yeah Yes, you can yeah, but the problem is Well, there are no there are no approved dies to do that you can actually do that you could use tri-pan blue for example and Injected they and that has been certainly been done in an animal was the University of Nebraska where Carl used to be Cameras there his lab has done a lot of that work and They're they're part of the hydrous development group because of that They figured that but they it's it's variable seems to work at different times during the day some channels are open And then the other problem is if you're doing at the time of surgery, it's it's it's hard to get it all the way around Well, so you technically theoretically you could do that But we have we don't have anything that's that we can put in to see those channels Easily at the time of surgery and do it in laboratory easy That's basically what they've done is to try to identify where the most likely it turns out that most of them are more mermasal Turns out they shut off doing different times during the day So it's it would be hard to find that would be great if you could do that one thing that We know is that if you go any of scope them at the time of surgery And they have a lot of pigment you can see areas where the where there's thick pigment that those are out So you can get them close to that so there are some cases where it's pretty easy to see where where the probably is If you're within a middle major to it seems to help that's what I'm the new the new the eyepass and Some of the in the hydrous are materials that are in that range I'm not sure what they cover them with but they're the eyepass the one that's going to go in the supercurtle space is Very bio compatible. It's the same material the company that owns the The it's a cardiology company that ended up making those things Yep But again, we'll see what happens is the cylinders that space the supercurtle space is a lot of blood flow there It's not an easy area. We used to do of course cyclo dialysis as a surgical procedure work beautifully or they were high-potenance or it didn't work About 30 30 30 we can never figure out who the hell it would work on they are The the other two are just like stents and that and it turns out that the eye stent you can maybe with some of the new they even the eye excuse me the mini shunt is And it's much larger than these MRI compatible They're looking at that. I guess the new Tesla coming out is gonna be a little higher and they'll have to redo their studies on that But everything that we have now All everything we're putting in there is work